Restless legs: what are the symptoms and what helps?

With restless legs, you have an unpleasant sensation in your legs and a strong urge to move them. It can feel like itching, tingling, pulling, or burning, or as if something is moving under the skin. Moving, stretching, or walking around for a bit usually provides relief. As soon as you sit still or lie down again, the symptoms often return.

The medical name is restless legs syndrome, also known as restless legs syndrome (RLS).

Restless legs are not a muscle disease, nor are they the same as ordinary leg cramps. It is a neurological disorder that occurs primarily during rest and often in the evening and at night.

How do you recognize restless legs?

Doctors use four key characteristics to recognize restless legs syndrome:

• You have a strong urge to move your legs, usually accompanied by an unpleasant sensation.
• The symptoms start or worsen when you are sitting or lying still.
• Movement reduces the symptoms, at least as long as you are moving.
• The symptoms are more pronounced in the evening or at night than during the day.

There is no blood test or scan that can diagnose RLS. The diagnosis is made based on the pattern of symptoms. Other conditions that can cause similar symptoms, such as nerve problems, muscle spasms, or restlessness caused by medication, must sometimes be ruled out.

In some people, not only the legs but also the arms are restless. In addition, periodic leg movements occur during sleep in many people with RLS: the legs twitch or kick automatically. The person usually does not notice this themselves. These movements during sleep are different from RLS itself, but often occur together with it. How common is restless legs? Restless legs are relatively common. Dutch studies show that the symptoms occur in a significant portion of the population and are reported more frequently by women and older people. In a Dutch study among people aged 50 and older, approximately 7 percent met the criteria for probable RLS. Not everyone with RLS suffers from it to the same extent. For some people, it occurs occasionally, for example during a long car ride or an evening on the couch. For others, the symptoms are present almost daily and disrupt their night's rest.

Why are restless legs particularly worse in the evening and at night?

RLS has a distinct day-night rhythm. The symptoms usually intensify as the evening progresses and are most pronounced at night. Consequently, the symptoms arise precisely at times when you want to relax or sleep.

This can happen, for example:

• in bed;
• on the couch;
• during a long car ride;
• at the cinema;
• during a long meeting or flight.

The combination of sitting still and the time of day means that RLS can be particularly bothersome in the evening.

An important symptom is therefore not only the restless feeling in the legs, but also poor sleep. People may have difficulty falling asleep, wake up frequently, or struggle to fall back asleep. As a result, they may be tired or sleepy during the day. Sleep problems are among the most significant consequences of RLS.

What causes restless legs?

For many people, no single clear cause can be identified. Hereditary predisposition plays an important role. According to the American guidelines, approximately half of people with RLS have a first-degree relative with the same condition.

The risk of RLS is also higher under certain circumstances, including:

• Hereditary predisposition: RLS often runs in families.
• Age: symptoms are generally seen more frequently as people get older.
• Pregnancy: RLS occurs significantly more often during pregnancy, especially later in pregnancy.
• Severe kidney problems: people with severe kidney failure, in particular, experience RLS more frequently.
• Iron deficiency: an iron deficiency can trigger or worsen RLS.
• Certain medications: including some antidepressants, antipsychotics, anti-nausea medications that block dopamine, and some antihistamines can trigger or worsen symptoms.

Alcohol and caffeine can worsen symptoms in some people. Certain other factors, such as untreated sleep apnea, can also play a role.

Restless legs and iron

The relationship between iron and RLS is unique. Iron is involved in various processes in the brain, including the dopamine system. In people with RLS, evidence has been found for reduced iron availability in certain brain regions. Furthermore, people with an iron deficiency in the body have RLS more frequently.

In addition, it is important to distinguish between iron in the blood and iron in the brain. Therefore, a normal iron level in the blood does not rule out RLS.

Is taking iron beneficial?

Research shows that iron treatment can reduce the severity of RLS in a subset of people. A 2019 Cochrane review, which included ten studies with a total of 428 adults, found an improvement compared to placebo. However, the evidence was not substantial enough to determine precisely which patients benefit most from which form of iron. Moreover, a significant portion of the research focused on intravenous iron rather than iron tablets. Therefore, international sleep medicine guidelines recommend monitoring iron status in people with clinically relevant RLS. This involves examining not only ferritin but also, among other factors, transferrin saturation. The American guideline uses different thresholds for RLS than those typically used for general iron deficiency. The guideline cites, among other things, ferritin levels lower than 75 micrograms per liter or a transferrin saturation lower than 20 percent as values ​​at which iron treatment may be considered. These thresholds are partly based on expert consensus and are not the same as the usual criteria for iron deficiency in the general population. The approach varies by guideline and by patient. Therefore, it is not advisable to start iron tablets on your own. Too much iron can be harmful, and iron tablets can cause gastrointestinal issues.

Does magnesium help with restless legs?

Magnesium is often mentioned as a remedy for restless legs. The reasoning behind this is understandable: magnesium plays an important role in muscles and nerves.

However, the evidence for RLS is insufficient. A systematic review from 2019 found only one randomized controlled trial and a few small patient reports. Based on this, the researchers could not determine whether magnesium works and for which people it might potentially help.

Since then, a few newer small studies on dietary supplements have appeared, but there are limitations there as well, such as small study groups and an increased risk of bias. Therefore, magnesium cannot currently be considered a well-substantiated standard treatment for RLS.

What can you do yourself?

There is no lifestyle measure that will make RLS disappear for everyone. However, certain habits can reduce symptoms or prevent them from worsening.

For example, you can try to:

• get enough exercise during the day;
• maintain a regular sleep schedule;
• limit caffeine, especially later in the day;
• avoid alcohol in the evening if you notice it worsens symptoms;
• not smoke;
• interrupt prolonged sitting as much as possible;
• avoid very intensive exercise right before bed if you notice it triggers symptoms.

The American guideline recommends, as a first step, addressing factors that can worsen RLS, including alcohol, caffeine, and certain medications.

However, the scientific basis for individual lifestyle recommendations is limited. It is therefore better to view them as practical measures you can try out rather than as proven treatments.

Do stretching, massaging, heat, or cold help?

Movement often provides temporary relief for RLS. Standing up and walking for a moment, stretching the calves, or massaging the legs can therefore provide relief.

A warm bath, a shower, or even cooling down can also be pleasant for some people. However, there has been little good research done on this. If such a measure temporarily reduces your symptoms and is safe, you can certainly use it as a supplement.

And what about paracetamol or a bar of soap?

Paracetamol

Paracetamol is a painkiller. With RLS, pain is not the primary symptom, but rather an unpleasant sensation and an urge to move.

There is no solid evidence that paracetamol treats RLS. Therefore, it is not a standard treatment for restless legs.

A bar of soap under the sheet

Soap in bed is a well-known folk remedy. However, there is no reliable scientific evidence that this reduces RLS. It can therefore be considered, at most, a personal experience, not a proven treatment.

Restless legs during pregnancy

RLS clearly occurs more frequently during pregnancy. In a large meta-analysis, approximately 21 percent of pregnant women had RLS; symptoms became more frequent as the pregnancy progressed. After childbirth, symptoms decrease again in many women.

During pregnancy, it is important not to use medication or supplements for RLS indiscriminately. The safety of a treatment must always be weighed against the potential consequences for the pregnancy.

Because iron deficiency is more common during pregnancy and can be associated with RLS, it may be wise to discuss the symptoms with the midwife, general practitioner, or gynecologist. They can assess whether blood tests are necessary and whether treatment of a potential iron deficiency is worthwhile.

Which medications are used for severe restless legs?

If RLS is frequent, severely disrupts sleep, and lifestyle adjustments are insufficient, pharmacological treatment may be considered.

Treatment has changed in recent years. Older guidelines placed relatively strong emphasis on medications that stimulate the dopamine system, such as pramipexol and ropinirol. It has since become clearer that long-term use of these agents can lead to augmentation: the RLS symptoms then actually gradually worsen. For example, they may start earlier in the day, develop more quickly while sitting still, or spread to other parts of the body.

The current US guideline therefore recommends gabapentin, gabapentin enacarbil, and pregabalin as treatments for adults with RLS, and specifically advises caution with dopamine agonists as standard treatment due to the risk of augmentation. The appropriate treatment depends on, among other things, the severity of the symptoms, other conditions, kidney function, other medications, and possible side effects. Gabapentin and pregabalin, for example, can cause drowsiness and dizziness. Are you already taking pramipexol or ropinirol? Do not stop taking them abruptly. Discuss changes in treatment with your GP or specialist.

What is augmentation?

Augmentation is a specific complication of long-term treatment with dopaminergic medication for RLS.

With augmentation, symptoms change in such a way that, for example:

• they start earlier and earlier in the day;
• they occur more frequently when you are sitting still;
• the symptoms become more severe;
• they last longer;
• they spread from the legs to the arms, for example.

This can make it seem as if the disease is worsening, while the change is actually related to the treatment. This is a known problem, especially with long-term use and higher dosages of dopamine agonists.

Can a blood test detect restless legs?

No. There is no blood test that can determine if you have RLS. The diagnosis is made based on your symptoms and their typical pattern.

Blood tests can help identify factors associated with RLS. Depending on your situation, a doctor may, for example, look at:

• ferritin;
• serum iron and transferrin saturation;
• kidney function;
• hemoglobin and other values ​​when there is reason to do so.

An abnormal iron level does not automatically mean that the iron deficiency is the cause of the RLS. Conversely, a normal blood value does not rule out RLS.

When should you see your GP?

Make an appointment with your GP if the symptoms recur regularly and disrupt your sleep or daily functioning.

This certainly applies if:

• you have difficulty falling asleep or wake up frequently due to the symptoms;
• you are very tired or sleepy during the day;
• the symptoms occur increasingly often or earlier in the day;
• you suspect that a medication is causing or worsening the symptoms;
• you are pregnant and suffer greatly from restless legs;
• you are already using medication for RLS and the symptoms change or worsen;
• you are unsure whether it is actually RLS.

Other symptoms also warrant assessment. Numbness, loss of strength, or persistent pain in a leg are not typical of RLS and may indicate another cause. A leg that suddenly becomes swollen, red, warm, and painful is also not consistent with restless legs. Contact a doctor immediately if you experience such symptoms, as thrombosis, among other conditions, must be ruled out.

Conclusion

Restless legs, or restless leg syndrome, cause an unpleasant sensation in the legs and a strong urge to move them. The symptoms occur primarily during rest, are worse in the evening and at night, and temporarily decrease with movement.

For most people, no single clear cause can be identified. Hereditary predisposition plays an important role. Pregnancy, severe kidney problems, iron deficiencies, and certain medications can also be associated with RLS.

The first step is to address factors that can worsen the symptoms, such as alcohol, caffeine, and certain medications. Exercise and a regular sleep schedule can also help.

Iron can help some people with RLS, but you should not use iron supplements indiscriminately. If necessary, have your iron status assessed and discuss the results with your GP. The evidence is insufficient for magnesium, paracetamol, and home remedies such as a bar of soap.

If you are still suffering a lot despite these measures, are sleeping poorly, or are the symptoms getting progressively worse, discuss this with your GP. Various treatments are available, and the choice depends on your symptoms and personal situation.